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- - APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 F' P O BOX 2009, STOCKTON, CA 95201 3 _P_ERMIT EXPIRES 1 YEAR FROM DATE I5SIIED .(Complete in Triplicate) Application is hereby made to San Joaquin County for a.permit to construct and/or install the work herein described. This application is made in ceeiliance with San Joaquin County Ordinance No. 549 and 3.862 and the Rules and Regulations of San Joaquin County Public Health Services. T _1 Job Address I�Z /`l�lC�GIE' �° •City �Ct!��6Zat Size/Acreage Owner's Name �� !�'/ � L Address 9 yl�f�� Y Phone ` 3t ll�f Canlractor ��Ur �'Scs✓�.J Address 76 F! Wlf44 �0 License fro. 4' y Phone z /Z, I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17.7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Fl Domestic/Private O-Gravel Pack ❑ Tracy Type of Casing— Specifications 11 Public 1-1`01her F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P.. State Work Done_ u -Well Destruction ❑ . Well Diameter Sealing Material &.Depth Depth Tiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is i available within 200 feet.) i Installation will serve: Residence Commercial Other Number of living units: Number-of bedrooms Character of ssoll to a depth of 3 feet: Water table depth SEP TIC TANK: ❑ Type/Mfg44 Capacity No. Compartments 'PKG. TREATMENT PLT. ❑ [ r Method of Disposal ! Distance to nearest: Well Foundation Property Line 3 LEACHING LINE Cl No. b Length of lines Total length/size �6 FILTER BED _ ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS Depth Size . 33 I Number 4 �l SUMPS Ll Distance to nearest: Well ;'00_' Foundation Property Line I 0 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County ,Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature asnifiea the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion 44*f California." The applicants I c uir rns ns. Complete drawing on reYarse side. Sf ��✓ � / i Signed X , „ .__ Title: Data: i FOR DEPARTMENT USE ONLY Application Accepted byData Area., A44,01 Y Pit or Grout Inspection by Date Final Inspection by Date �L68'Z Additional omme _ Applica t turn ll copies to: San J aqu ountq Pub c Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE T REMITTED CASH RECEIVED BY DATE PERMIT-NO. . EH 13-24 4aEV.f i n sr 0 t:7E EH'ti•2a / r